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13 th INTERNATIONAL CONFERENCE ON INTEGRATED CARE Berlin, Germany, April 11 – 12, 2013

Coordination and governance mechanisms to enable the conditions for integrated care of chronic conditions Juan Tello , Erica Barbazza and Hans Kluge Division of Health Systems and Public Health Health Services Delivery Programme. 13 th INTERNATIONAL CONFERENCE ON INTEGRATED CARE

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13 th INTERNATIONAL CONFERENCE ON INTEGRATED CARE Berlin, Germany, April 11 – 12, 2013

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  1. Coordination and governance mechanisms to enable the conditions for integrated care of chronic conditions Juan Tello, Erica Barbazza and Hans Kluge Division of Health Systems and Public Health Health Services Delivery Programme 13th INTERNATIONAL CONFERENCE ON INTEGRATED CARE Berlin, Germany, April 11 – 12, 2013

  2. Dec 2014 Context: WHO work plan towards policy options for the integration of care in the Region PHC country studies: Horizontal analysis Workshop: Modern health care delivery systems, care coordination and the role of hospitals Review of draft paper on coordinated/integrated care delivery European Regional Action Framework on integrated people – centred health services delivery towards UHC 2011 2012 2013 Launch of NCD/PHC evaluation tool Governance of health care providers Ongoing implementation of Primary Health Care Evaluation Tool (PCET) Launch of case studies on HSS for improved NCD outcomes Country case studies on integrated care Policy options Knowledge synthesis and consultation process with Member States Division of Health Systems and Public Health April 2013

  3. Dec 2014 Context: WHO work plan towards policy options for the integration of care in the Region PHC country studies: Horizontal analysis Workshop: Modern health care delivery systems, care coordination and the role of hospitals Review of draft paper on coordinated/integrated care delivery European Regional Action Framework on integrated people – centred health services delivery towards UHC 2011 2012 2013 Launch of NCD/PHC evaluation tool Governance of health care providers Ongoing implementation of Primary Health Care Evaluation Tool (PCET) Launch of case studies on HSS for improved NCD outcomes Country case studies on integrated care Policy options Knowledge synthesis and consultation process with Member States Division of Health Systems and Public Health April 2013

  4. Context: Integrated care in WHO European Region Integrated care: The management and delivery of health services such that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services, through the different levels of care, and according to their needs throughout the life course (PAHO, 2011) Integrated people-centred care Division of Health Systems and Public Health April 2013

  5. BALTIC CASE STUDIES Division of Health Systems and Public Health April 2013

  6. Background: Integration from the orientation of public stewards and the governance function • Initiative A • Initiative B • Initiative C • Integrated people – centred health services delivery . . . Drivers for change What processes and mechanisms are used by public stewards to enable a shared vision and aligned action across integration initiatives towards system goals? Division of Health Systems and Public Health April 2013

  7. Governing within and across initiatives towards the integration of care Initiative A Initiative B Initiative C . . . Efforts towards integration Priority setting & planning Organizing & managing action Components of Governance Accountability, monitoring & evaluation Division of Health Systems and Public Health April 2013

  8. What are coordination & governance mechanisms? • The tools and measures employed by stewards to define the ‘rules of the game’ - the institutional relationships (both formal and informal or hard and soft) shaped or re-shaped to enable the conditions for coordinated and aligned efforts to be enabled • Through the purposeful and strategic use of mechanisms, the system’s efforts may be guided towards specified goals Division of Health Systems and Public Health April 2013

  9. Countries of study: The Baltic countries • The Baltic Countries: Estonia(1,339,928), Latvia (2,058,184) and Lithuania(3,222,186) (2011) • Series of reforms beginning early 1990s following independence: • Health financing • Primary health care • Hospital sector • Shift from centralized to decentralized organization of health system • Share common health challenges of cardiovascular diseases, cancers and injuries as leading causes of death Division of Health Systems and Public Health April 2013

  10. Methodology Division of Health Systems and Public Health April 2013

  11. PRELIMINARY FINDINGS: I. GOVERNANCE WITHIN INITATIVES II. GOVERNANCE ACROSS INITIATIVES Division of Health Systems and Public Health April 2013

  12. Findings I: Initiatives towards the integration of care highlighted in countries of study Division of Health Systems and Public Health April 2013

  13. Lithuania (I): Eastern Lithuanian Cardiology Project • Drivers for change in early 2000s: • Uneven distribution of specialists • Overuse of central facilities • Lack of coordination between levels of care • Poor health outcomes • Objective: Coordination between PHC prevention, secondary care outpatient cardiology services and specialist, tertiary care for cardiology services in eastern Lithuania. • Steward: Vilnius University Hospital SantariskuKlinkikos, Director • Funding: EU structural funds and Ministry of Health • Start date:2003 Division of Health Systems and Public Health April 2013

  14. Lithuania (II): Eastern Lithuanian Cardiology Project Priority setting & planning Organizing & managing action Accountability monitoring & evaluation Division of Health Systems and Public Health April 2013

  15. Enabling the conditions towards integration: Lessons learnt • There is a delicate balance between mechanisms to enable the ‘right’ conditions necessary towards a desired end • Ex. Changes in payment • Ex. Changes in stewardship • Clear lines of interactions and a strong stewardship role in the eastern region allowed a clear direction throughout the development and implementation of the initiative • Successful in creating a system-orientation to the efforts put in place, creates the conditions for long-term sustainability • The mechanisms and processes put in place may evolve overtime (with the phases of an initiative) and the for need foresight to understand and respond to this is necessary Division of Health Systems and Public Health April 2013

  16. Estonia: Evidence based guidelines for diagnosis and care of selected conditions Priority setting & planning Organizing & managing action Accountability monitoring & evaluation Division of Health Systems and Public Health April 2013

  17. Estonia: Bonus payment for treatment of selected chronic conditions in PHC Priority setting & planning Organizing & managing action Accountability monitoring & evaluation Division of Health Systems and Public Health April 2013

  18. Lithuania: Screening programmes for selected chronic conditions Priority setting & planning Organizing & managing action Accountability monitoring & evaluation Division of Health Systems and Public Health April 2013

  19. Latvia: Strengthening prevention and promotion in PHC Priority setting & planning Organizing & managing action Accountability monitoring & evaluation Division of Health Systems and Public Health April 2013

  20. Summary: Common processes and mechanisms across components of governance Division of Health Systems and Public Health April 2013

  21. Findings II: Governing across initiatives towards the integration of care • Observe an absence of processes and mechanisms across initiatives to achieve a common, integrated, effort towards more integrated care • The implications of this includes: • An inability to overcome health system barriers • Challenges to target the most vulnerable populations and address health inequalities • Perpetuated inefficiencies as structures and systems are “vertically” implemented. Division of Health Systems and Public Health April 2013

  22. Concluding thoughts • Enabling governance across initiatives (system/policy perspective) as the means to: • Create the architecture for lines of accountability (mandate, means/resources, supervision, enforceability). • Support long-term sustainability. • Tackle those system barriers that impede scaling-up of integration initiatives e.g. alignment of incentives for providers, development of human resources for health, e-health and management of information (clinical, activities, others), access to technologies, use of pharmaceuticals, public health/population based interventions, among others. • Tackle health inequalities derived from vertical/ad hocinitiatives and holistically address health needs with a human rights’ and people-centred perspectives. Division of Health Systems and Public Health April 2013

  23. THANK YOU Please send additional comments to Juan Tello telloj@who.int Division of Health Systems and Public Health April 2013

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